Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review

The NQF selected a Technical Expert Panel to represent a broad group of public and private stakeholders (Additional file 1). Based on the recommendations of this panel, we chose six regions of the country to represent geographic diversity and to include national leaders in HIT (Table 1). The sampling strategy was purposeful to identify study participants involved in clinical care, as well as information technology (IT) professionals with responsibility for transitional care. We employed a snowball methodology using our own contacts, contacts identified by the NQF, the Internet, and colleagues of the people that we contacted [10]. The clinicians were representative of different types of facilities. We were particularly interested in identifying clinicians on both sides of a care transition. For example, in Interview 1 we included a physician from a hospital and a physician from a post-acute nursing facility who had transferred patients to each other.

We conducted six one-hour ‘focus group-style interviews’ with clinicians and IT professionals. Interviews were conducted by two co-investigators (LS or PCD) over the telephone following a semi-structured interview guide (see Additional file 1). We developed the guide on the basis of the biomedical literature, our previous experience conducting qualitative interviews, and our own experiences as physicians and nurses. The study was designated as exempt from informed consent by the Partners HealthCare Institutional Review Board.

We chose to use a closed coding process. Codes were assigned from a priori domains within the Agency for Healthcare Research and Quality (AHRQ) Care Coordination Measurement Framework [3]. This model was chosen due to inclusion of broad approaches as well as nine specific care coordination activities. For ease of reporting, we have collapsed the nine care coordination activities into three levels which align with the AHRQ framework: provider-level, patient-level, and system-level (Table 2).

Verbatim transcriptions of interviews were entered into QSR NVivo for coding and analysis. The interviews were coded through a two-person consensus approach (LS and PCD). The two coders read each transcript multiple times and annotated it using NVIVO software. Conflicts were resolved through consensus between the two reviewers. In order to describe the extent to which HIT is used for care coordination, we identified the overlap of the broad approach ‘HIT-enabled Coordination’ with each of the nine care coordination activities. In other words, we are presenting the responses that we assigned the code for AHRQ broad approach ‘HIT-enabled Coordination’ as well as one of the nine care coordination activity codes.

In addition to the interviews, we conducted a review of the literature. Our objective was to identify intervention studies conducted to improve transfer of information during transitions of care, with a focus on HIT interventions. We searched MEDLINE®, CINAHL®, and Embase with no date restrictions. Search terms related to information exchange during care transitions were tailored to each database and combined with search terms related to HIT. For example, MeSH terms included Continuity of Patient Care, Patient Discharge, Aftercare, Consultation and Referral, Patient Transfer, Transportation of Patients, and Medical Documentation. A detailed description of the Literature Review Methods are included in Additional file 2.

‘Establishing accountability’ concerns interpersonal relationships and is a process that is governed by local policies and customs. HIT was used for this care coordination activity, as described in Interview 1 (Table 3, Response 1). In this instance, the negotiation of responsibility occurs in a face-to-face meeting, but clinician accountability was tracked using a web-based tool.

The AHRQ framework distinguishes between two types of Communication: Interpersonal communication and Information transfer [3]. We did see that email was used for interpersonal communication, which allows hand-offs to be performed asynchronously (Table 3, Response 2). However, due to the lack of interoperability, none of the regions reported electronic information transfer. Instead, medical records were printed out and hand-carried by ambulance personnel (Table 3, Response 3). The ED and acute care hospitals in interview 6 shared the same EHR, but they lacked interoperability with SNF and HHA organizations. We asked about effectiveness of information transfer and how clinicians respond to missing information and found that significant care coordination gaps exist due to the lack of interoperability (Table 3, Responses 3, 4 and 5).

There were no examples of innovative HIT tools to facilitate transitions. We did note that there were many organizations that have hired nurse case managers to facilitate transitions between acute care hospitals and EDs. Organizations in interviews 1 and 3 use a case manager and social worker to integrate care between inpatient and outpatient teams. Long-term acute care hospitals in interview 2 used nurses in a similar role. EDs in interviews 3, 4, and 5 employed nurses to make follow-up appointments and arrange transfer back to sub-acute facilities. As a nurse from a home health agency in nterview 3 explained, the lack of interoperability forces clinicians to do clerical work (Table 3, Response 6).

In summary, HIT was occasionally used in each of the provider-level care coordination activities, but the processes were inefficient due to the lack of interoperability. Interoperability would spur innovative HIT tools to assist nurses and physicians while they are searching for missing information.

HIT was used to assess patients’ needs and goals. ACH respondents from Interviews 3 and 6 spoke about an EHR patient portal that included shared decision-making tools and a place to enter patient goals (Table 4, Response 7).

Clinicians were not able to create a proactive plan of care electronically, though an ACH respondent in Interview 3 mentioned that a hospital in their network was using an inpatient EHR to help patients understand their own plan of care (Table 4, Response 8). We have published a separate paper about the current and future state of longitudinal care plans, where we reported that these plans were not truly longitudinal since they exist in one setting and were not carried forward with the patient [11].

There were several electronic tools to support the activity ‘Monitor, follow-up and respond to change,’ which is the process by which clinicians respond to changes in clinical status for an individual patient. One site had a standardized note template in the EHR for post-discharge phone calls, another had a tele-management program for congestive heart failure and another had an email trigger that automatically sent an email when a patient from the medically complex child service was admitted anywhere within the system (Table 4, Response 9).

There were only a few examples of the use of HIT to support patients’ self-management goals. Three regions utilized a patient portal where patients could view their own medication lists, though clinicians thought that the information should be tailored to patient literacy level. One respondent from a home health agency pointed out that the software that they were using was not sophisticated enough to help clinicians with individualized support for patients’ goals (Table 4, Response 10).

In summary, patient portals were used to support patient-level care coordination and case management programs were in place to follow-up with patients. There were few examples of HIT tools that clinicians and patients could use together to tailor management. There were no examples of free-standing patient HIT tools which were interoperable with EHRs.

One of the activities that should be addressed at a system-level is ‘Link to community resources,’ which are defined by AHRQ as, “any service or program outside the health care system that may support a patient's health and wellness (e.g., Medicaid, food stamps, social services, educational resources, support groups, or Meals on Wheels).” The only electronic tool for this activity was cited by respondents from a SNF in interview 1 who described an Internet directory of nursing facilities, but focused on the shortcomings of the system (Table 5, Response 11).

The ninth care coordination activity is ‘Align resources with patient and population needs.’ Many respondents use risk stratification tools to identify the sickest patients. An HHA respondent in Interview 4 described a paper tool completed in the patient’s home as an education tool to highlight factors such as poly-pharmacy, chronic diseases, and multiple hospitalizations. A respondent from a SNF in Interview 2 described an electronic tool from a commercial EHR company that helps to identify patients at high risk according to their symptoms. Interview 3 HHA gathers data electronically on the number of admissions, medications, and chronic conditions to develop a risk score; patients with high scores have two ‘front-loaded’ home visits soon after discharge. The Interview 6 hospital explained that they use a validated tool that has been integrated into the EHR, called LACE, which is an acronym for Length of stay, Acute admissions through the ED, Co-morbidities, and ED visits in the past 6 months [12]. An ED respondent from Interview 3 described an EHR alert for patients with three ED visits or a readmission in the past 30 days. An ACH respondent in Interview 6 described sophisticated EHR tools that incorporate patient-specific data (Table 5, Response 12).

In summary, there were no examples of interoperability between an EHR and a computer system used by a community organization. There were many examples of HIT tools to align system-level resources with high-risk patients or populations.

Our literature search initially identified 173 citations. Each citation was reviewed by two reviewers and conflicts were resolved by consensus. After title-abstract review, 54 articles were included for full article review by two reviewers. Of these articles, 44 were excluded prior to data extraction due to the fact that they were not studies of interventions to improve information exchange during care transitions (see Additional file 2). The ten remaining articles were abstracted according to a standard format. Three of the articles described non-HIT interventions to improve information transfer across settings [13‐15]. We found seven articles which described the use of HIT for information transfer across care transitions [16‐22]. None of these interventions leveraged interoperable computer systems. A detailed summary of the results is included in Additional file 2.

The dataset supporting the conclusions of this article is available upon request as a 105 page pdf document. The dataset is not available as an electronic document because NVIVO file containing the two reviewers’ annotations became corrupted due to improper syncing between the hard drive and secure shared drive.